Twenty-five-year imaging follow-up of an untreated giant Spetzler–Martin grade V Brain arteriovenous malformation associated with cerebral infarction and epilepsy

Brain arteriovenous malformations (BAVMs) are typically associated with intracranial hemorrhage, whereas ischemic stroke associated with a high-grade BAVM is an exceptionally rare complication. We present the 25-year long-term imaging follow-up of a 39-year-old male with a giant Spetzler–Martin grade V BAVM. Initially diagnosed at age 14 via magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) due to a visual deficit, the complex lesion was managed conservatively owing to prohibitive procedural risks. Twenty-five years later, the patient presented with acute left limb weakness and recurrent adult-onset epilepsy. Current diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) mapping demonstrated chronic ischemic changes in the bilateral frontal lobes and a new acute-to-subacute infarction in the left parietal lobe. Concurrent MRA and MRI demonstrated a massive 13.5 × 6.3 cm nidus with prominent vascular flow voids and deep venous involvement. The patient received supportive medical management and antiseizure therapy. Motor function showed near-complete recovery at 3 months, although recurrent minor seizures persisted during longer-term follow-up. This 25-year imaging follow-up documents the long-term imaging follow-up of a giant, untreated Spetzler–Martin grade V BAVM and documents the occurrence of delayed ischemic complications during long-term follow-up of a giant BAVM. In extreme-risk, unruptured cases, conservative management with imaging surveillance is a carefully considered option, though it carries ongoing long-term risks.